Audit Planning & Report Form
Please complete this form for all audits in your service area
Name of Audit: Transplant Data Audit
Division: Service: Area:
Start Date: Finish Date:
Lead Name:
Team Members:
Auditor Title:
Name: Name:
Sponsor: Line Manager:
Title: Title:
Reference to Health and Disability Sector Standard: Consumer Rights; Organisational Management; Continuum of Service
Delivery; Safe and Appropriate Environment; Restraint Minimisation and Safe Practice; Infection Control
Section One – Audit Needs Analysis
Purpose of Audit
e.g. description of the intended outcome of the audit objectives, where possible describe commitment to improvement in quality of
care/practice
Enter purpose of audit here
Rationale / Priority
E.g., regulation, certification, accreditation, divisional strategic/business plan/requirement, re-audit; improvement opportunity, change
in practice/policy/standard/protocol/guideline, actual or suspected risk/problem/issue or variance in practice/outcome.
Enter rationale / priority here
Standard / Policy / Procedure / Topic to be Audited
List relevant policy/procedure/protocol, guidelines(s), clinical indicator or defined best practice where references are possible. Include
reference number or attach copy if appropriate
Enter Standard / Policy / Procedure / Topic to be Audited
Section Two – Clinical Audit Plan (complete all sections, as required, prior to commencing the audit)
Audit Method/Procedure
Sample size, sample selection data collection method, method of data analysis, how confidentiality is to be protected
retrospective/concurrent/prospective
List details here
Resources Required
Including any equipment/personnel/time/cost
Line Manager(s) / Sponsor Approval to proceed
Signatures
Date:
TEMPLATE PROVIDED BY CANTERBURY DISTRICT HEALTH BOARD, CHRISTCHURCH HOSPITAL
Document Unique Identifier, Document Title, Version Number, Effective Date Page X of X
Audit Planning & Report Form
Section Three – Audit Report, including Action Plan (to be populated once audit completed)
Audit Findings / Results
Include response rate, graphs, raw data, any deviations from plan, monitoring strategies, as appropriate. Insert/attach report
Enter finding / results here
Audit Conclusions
Interpretation of audit findings/identification of underlying cause(s) of errors/results/
Enter audit conclusions here
Recommendations and agreed actions
Include action plan with time frame; staff responsible for completion; implementation and, if required, monitoring; evaluation/update associated
documentation. Date of re audit if planned.
Enter recommendations and agreed actions here
Line Manager(s) / Sponsor Agreement on recommendations and agreed actions
TEMPLATE PROVIDED BY CANTERBURY DISTRICT HEALTH BOARD, CHRISTCHURCH HOSPITAL
Document Unique Identifier, Document Title, Version Number, Effective Date Page X of X
